Unstable gait due to spasticity of the rectus femoris: Gait analysis and motor nerve block

Multisite Transcutaneous Spinal Stimulation for Walking and Autonomic Recovery in Motor-Incomplete Tetraplegia: A Single-Subject Design

OBJECTIVE

This study investigated the effect of cervical and lumbar transcutaneous spinal cord stimulation (tSCS) combined with intensive training to improve walking and autonomic function after chronic spinal cord injury (SCI).

METHODS

Two 64-year-old men with chronic motor incomplete cervical SCI participated in this single-subject design study. They each underwent 2 months of intensive locomotor training and 2 months of multisite cervical and lumbosacral tSCS paired with intensive locomotor training.

RESULTS

The improvement in 6-Minute Walk Test distance after 2 months of tSCS with intensive training was threefold greater than after locomotor training alone. Both participants improved balance ability measured by the Berg Balance Scale and increased their ability to engage in daily home exercises. Gait analysis demonstrated increased step length for each individual. Both participants experienced improved sensation and bowel function, and 1 participant eliminated the need for intermittent catheterization after the stimulation phase of the study.

CONCLUSION

These results suggest that noninvasive spinal cord stimulation might promote recovery of locomotor and autonomic functions beyond traditional gait training in people with chronic incomplete cervical SCI.

IMPACT

Multisite transcutaneous spinal stimulation may induce neuroplasticity of the spinal networks and confer functional benefits following chronic cervical SCI.

French clinical guidelines for peripheral motor nerve blocks in a PRM setting

INTRODUCTION

Motor nerve blocks with anesthetic drug for local anesthesia are commonly used in physical and rehabilitation medicine (PRM), especially in the field of spasticity. Guidelines in this context are currently lacking.

METHOD

Eighteen experts selected on the basis of their recognized experience by the scientific committees of the French PRM (SOFMER) and Anesthesia and Intensive care (SFAR) societies were invited to work and propose guidelines for the use of loco-regional anesthetic drug for motor nerve blocks in PRM setting. Eight issues were addressed: which neural blocks for which indications; drugs and contraindications; medical survey and attitude in case of adverse event; injection and guidance material; patient preparation and pain relief; efficacy assessment; patient information; education of PRM physiatrists. The Medline, Cochrane and Embase databases for the period 1999 to 2018 were consulted and 355 papers analyzed. The drafts were commented then approved by the whole group using electronic vote, before final approval by scientific committee of each society.

RESULTS

No scientific evidence emerged from the literature. Thus, these guidelines are mainly based on the opinion of the expert panel. Guidelines for each issue are reported with the main points of arguments. The main question deals with the recommendation about doses for each drug: for lidocaine - up to 2mg/kg - "check contraindications, emergency truck available, no need of previous anesthetic consultation nor presence of anesthetic physician"; for ropivacaine - up to 1.5mg/kg, with a maximum of 100mg - the same but after intravenous line. Beyond these doses, SFAR guidelines have to be applied with the need of anesthetic physician.

CONCLUSION

These are the first organizational guidelines devoted to increase the security of motor nerve block use in PRM settings.

Effects of Locomotor Exercise Intensity on Gait Performance in Individuals With Incomplete Spinal Cord Injury

BACKGROUND

High-intensity stepping practice may be a critical component to improve gait following motor incomplete spinal cord injury (iSCI). However, such practice is discouraged by traditional theories of rehabilitation that suggest high-intensity locomotor exercise degrades gait performance. Accordingly, such training is thought to reinforce abnormal movement patterns, although evidence to support this notion is limited.

OBJECTIVE

The purposes of this study were: (1) to evaluate the effects of short-term manipulations in locomotor intensity on gait performance in people with iSCI and (2) to evaluate potential detrimental effects of high-intensity locomotor training on walking performance.

DESIGN

A single-day, repeated-measures, pretraining-posttraining study design was used.

METHODS

Nineteen individuals with chronic iSCI performed a graded-intensity locomotor exercise task with simultaneous collection of lower extremity kinematic and electromyographic data. Measures of interest were compared across intensity levels of 33%, 67%, and 100% of peak gait speed. A subset of 9 individuals participated in 12 weeks of high-intensity locomotor training. Similar measurements were collected and compared between pretraining and posttraining evaluations.

RESULTS

The results indicate that short-term increases in intensity led to significant improvements in muscle activity, spatiotemporal metrics, and joint excursions, with selected improvements in measures of locomotor coordination. High-intensity locomotor training led to significant increases in peak gait speed (0.64-0.80 m/s), and spatiotemporal and kinematic metrics indicate a trend for improved coordination.

LIMITATIONS

Measures of gait performance were assessed during treadmill ambulation and not compared with a control group. Generalizability of these results to overground ambulation is unknown.

CONCLUSIONS

High-intensity locomotor exercise and training does not degrade, but rather improves, locomotor function and quality in individuals with iSCI, which contrasts with traditional theories of motor dysfunction following neurologic injury.

Primary and secondary gait deviations of stroke survivors and their association with gait performance

[Purpose] Stroke survivors exhibit abnormal pelvic motion and significantly deteriorated gait performance. Although the gait of stroke survivors has been evaluated at the primary level pertaining to ankle, knee, and hip motions, secondary deviations involving the pelvic motions are strongly related to the primary level. Therefore, the aim of this study was to identify the kinematic differences of the primary and secondary joints and to identify mechanism differences that alter the gait performance of stroke survivors. [Subjects and Methods] Five healthy subjects and five stroke survivors were recruited. All the subjects were instructed to walk at a self-selected speed. The joint kinematics and gait parameters were calculated. [Results] For the stroke survivors, the range of motion of the primary-joint motions were significantly reduced, and the secondary-joint motions were significantly increased. Additionally, for the healthy subjects, the primary joint kinematics were the main factors ensuring gait performance, whereas for the stoke survivors, the secondary-joint motions were the main factors. [Conclusion] The results indicate that while increasing the range of motion of primary-joint movements is the main target to achieve, there is a strong need to constrain and support pelvic motions in order to improve the outcome of gait rehabilitation.

Joint torque variability and repeatability during cyclic flexion-extension of the elbow

Background

Joint torques are generally of primary importance for clinicians to analyze the effect of a surgery and to obtain an indicator of functional capability to perform a motion. Given the current need to standardize the functional evaluation of the upper limb, the aim of this paper is to assess (1) the variability of the calculated maximal elbow joint torque during cyclic elbow flexion-extension movements and (2) participant test-retest repeatability in healthy young adults. Calculations were based on an existing non-invasive method including kinematic identification and inverse dynamics processes.

Methods

Twelve healthy young adults (male n = 6) performed 10 elbow flexion-extension movement carrying five different dumbbells (0, 1, 2, 3 and 4 kg) with several flexion-extension frequencies (½, ¹/₃, ¼ Hz) to evaluate peak elbow joint torques.

Results

Whatever the condition, the variability coefficient of trial peak torques remained under 4 %. Bland and Altman plot also showed good test-retest, whatever the frequency conditions for the 0, 1, 2, and 3 kg conditions.

Conclusion

The good repeatability of the flexion-extension peak torques represents a key step to standardize the functional evaluation of the upper limb.

Chemodenervation for treatment of limb spasticity following spinal cord injury: a systematic review

STUDY DESIGN

Systematic review.

OBJECTIVES

To systematically review the literature on chemodenervation with botulinum toxin (BoNT) or phenol/alcohol for treatment of limb spasticity following spinal cord injury (SCI).

SETTING

British Columbia, Canada.

METHODS

EMBASE, MEDLINE, CINAHL, Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Trials were searched for English language studies published up until March 2014. Studies were assessed for eligibility and quality by two independent reviewers.

RESULTS

No controlled trials were identified. A total of 19 studies were included: 9 involving BoNT and 10 involving phenol/alcohol. Owing to the clinically diverse nature of the studies, meta-analysis was deemed inappropriate. The studies produced level 4 and level 5 evidence that chemodenervation with BoNT or alcohol/phenol can lead to improvement in outcome measurements classified in the body structure and function, as well as activity domains of the International Classification of Functioning, Disability and Health framework. The Modified Ashworth Scale (MAS) was the most commonly used outcome measure. All six studies on BoNT and three of the four studies on phenol/alcohol measuring MAS reported a decrease in at least one point. An improvement in MAS was not always associated with improvement in function. The effect of phenol/alcohol has the potential to last beyond 6 months; study follow-up did not occur beyond this time point.

CONCLUSION

Chemodenervation with BoNT or phenol/alcohol may improve spasticity and function in individuals with SCI. However, there is a lack of high-quality evidence and further research is needed to confirm the efficacy of these interventions.

Benefits of repetitive transcranial magnetic stimulation (rTMS) for spastic subjects: clinical, functional, and biomechanical parameters for lower limb and walking in five hemiparetic patients

Introduction. Spasticity is a disabling symptom resulting from reorganization of spinal reflexes no longer inhibited by supraspinal control. Several studies have demonstrated interest in repetitive transcranial magnetic stimulation in spastic patients. We conducted a prospective, randomized, double-blind crossover study on five spastic hemiparetic patients to determine whether this type of stimulation of the premotor cortex can provide a clinical benefit. Material and Methods. Two stimulation frequencies (1 Hz and 10 Hz) were tested versus placebo. Patients were assessed clinically, by quantitative analysis of walking and measurement of neuromechanical parameters (H and T reflexes, musculoarticular stiffness of the ankle). Results. No change was observed after placebo and 10 Hz protocols. Clinical parameters were not significantly modified after 1 Hz stimulation, apart from a tendency towards improved recruitment of antagonist muscles on the Fügl-Meyer scale. Only cadence and recurvatum were significantly modified on quantitative analysis of walking. Neuromechanical parameters were modified with significant decreases in H max⁡ /M max⁡ and T/M max⁡ ratios and stiffness indices 9 days or 31 days after initiation of TMS. Conclusion. This preliminary study supports the efficacy of low-frequency TMS to reduce reflex excitability and stiffness of ankle plantar flexors, while clinical signs of spasticity were not significantly modified.

Does the rectus femoris nerve block improve knee recurvatum in adult stroke patients? A kinematic and electromyographic study

Knee recurvatum (KR) during gait is common in hemiplegic patients. Quadriceps spasticity has been postulated as a cause of KR in this population. The aim of this study was to assess the role of rectus femoris spasticity in KR by using selective motor nerve blocks of the rectus femoris nerve in hemiparetic stroke patients. The data from six adult, post-stroke hemiplegic patients who underwent a rectus femoris nerve block for a stiff-knee gait were retrospectively analyzed. An extensive clinical and functional evaluation was performed and gait was assessed by motion analysis (kinematic, kinetic and electromyographic parameters) before and during the block realized using 2% lidocaine injected under a neurostimulation and ultrasonographic targeting procedure. The main outcome measures were the peak knee extension in stance and peak knee extensor moment obtained during gait analysis. No serious adverse effect of the nerve block was observed. The block allowed a reduction of rectus femoris overactivity in all patients. Peak knee extension and extensor moment in stance did not improve in any patient, but peak knee flexion during the swing phase was significantly higher after block (mean: 31.2° post, 26.4 pre, p < 0.05). Our results provide arguments against the hypothesis that the spasticity of the rectus femoris contributes to KR.